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Staffing Patterns Before and After Mandated Nurse-To-Patient Ratios in California's Hospitals




Teresa Serratt, R.N., MSN, PhD(c)

University of California, San Francisco, 2009

Purpose: This study identifies and describes changes in nurse staffing that may have occurred as a result of the enactment of nurse-to-patient ratios and whether these changes were associated with particular hospital characteristics, controlling for market factors and population factors.

Background and Significance: Acute care hospitals have faced increased financial pressures from diminishing reimbursement, the proliferation of new medical technology and increased patient severity of illness that required a more skilled workforce. In response to these pressures, hospitals reduced nursing staff with expectations that labor costs would decrease and hospital financial performance would improve. However, reports of medical errors and poor patient outcomes brought this strategy under scrutiny and led to the establishment of mandated minimum nurse-to-patient ratios in California. This study is timely as few studies have been conducted after the implementation of the nurse-to-patient ratios in the state of California to examine the statewide changes in nurse staffing as a result of this legislation.

Design and Method: This study utilized a secondary analysis of OSHPD Annual Financial Report data with a pre-post design in which individual hospitals were observed at two time points (1999/2000 and 2005/2006) using ordinary least squares regressions.

Key Findings: The descriptive analysis of mean productive hours (MPHs) for nurse staffing indicated nearly an additional hour of medical/surgical registered nurse time per patient day from 1999/2000 (4.36) to 2005/2006 (5.16). Also, medical/surgical registry nurse time per patient day increased from 1999/2000 (0.30) to 2005/2006 (0.88) by more than one half hour. Little changed in the other medical/surgical nurse categories of LVN, nurse aid, and clerical/administrative staff. MPH for `non-nurse' staffing indicated an increase in two staffing categories: diagnostic radiology (0.53 to 1.27) and respiratory therapy (0.35 to 0.83). The other categories (clinical laboratory, physical therapy, pharmacy, and total general services) showed little change in mean productive staffing hours (adjusted by patient days or service volume) from 1999/2000 to 2005/2006. Next, a regression model was calculated to predict changes in MPHs for medical/surgical total registered nurse staff (registered nurses and registry nurses) and found that the `above' category of MPHs in 1999/2000 had a moderate, significant negative association

(-1.2497, p=0.013) with changes in MPHs while the below category had a large, positive significant association (0.8761, p<0.000) with changes in medical/surgical total RN MPHs.

Implications for Health Policy: Mandated nurse-to-patient ratios may be a necessary step in creating an environment of quality patient care. Further research is needed to provide empirical evidence that these types of policies have the intended effect of improving healthcare in acute care hospitals

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